Bulletin 210802 — Preventive Care Bonus Projected Reports — September 2021

To assist physicians in determining which patients within the target population still require a preventive care service

To: Eligible Patient Enrolment Model (PEM) Physicians
Comprehensive Care Model (CCM), Family Health Group (FHG), Family Health Network (FHN), Family Health Organization (FHO), Blended Salary Model (BSM), Group Health Centre (GHC), St. Joseph’s Health Centre (SJHC), Weeneebayko Area Health Authority (WAHA), Rural and Northern Physician Group Agreement (RNPGA), GP Focus HIV (HIV)
Category: Primary Health Care Services
Written by: Negotiations Branch, Ontario Health Insurance Plan Division
Date issued: August 31, 2021

Preventive Care Bonus Projected Report

The purpose of this INFOBulletin is to remind physicians of the upcoming Preventive Care Bonus Projected Report used to determine which patients within the target population still require a preventive care service.

The Ministry of Health (Ministry) provides eligible physicians in Patient Enrolment Models (PEMs) with a Projected Preventive Care Target Population/Service Report (TPSR) semi-annually, in April and September, to assist them in determining their Target Population and the delivery of preventive care services.

As outlined in INFOBulletin #11192 all providers will receive their TPSR electronically via Medical Claims Electronic Data Transfer (MCEDT) to their Solo accounts. If you have not yet registered your solo billing number for MCEDT you will need to do so to receive this report. The ministry will only provide paper reports for those providers who continue to receive paper Remittance Advices.

Specifically, this report identifies:

• A physician’s Target Population including enrolled patients who meet the age and sex criteria for each of the five (5) preventive care categories;
• Eligible services provided to enrolled patients who have provided consent for each of the five (5) preventive care categories, according to Ministry records;
• Enrolled patients who have provided consent for whom any physician in the group has submitted a Tracking Code; and
• Enrolled patients for whom the enrolling physician has submitted an Exclusion Code.

The TPSR-Projected Report allows physicians to focus on providing any preventive care services not yet received by their target population for the remainder of the fiscal year. Submission of the Cumulative Preventive Care Bonus claims does not occur until April and at that time instructions for submissions are provided.

Note: The Influenza Vaccine is an annual service and is neither available nor administered to patients until late fall of each year. As no services have been provided the TPSR-Projected Report only provides the patients in the target population.

Physician eligibility

• All signatory physicians who are active with an eligible PEM on March 31st of each fiscal year are eligible for the Preventive Care Bonuses for that fiscal year.
• Family Health Group (FHG) and Comprehensive Care Model (CCM) physicians must meet the minimum roster size as of March 31^st of the fiscal year in order to be eligible for the bonuses. You can determine your roster size by reviewing your monthly Roster and Capitation Payment and Reconciliation Report which shows all patients that are enrolled to a physician and a total count of those patients.

The requirements for FHG and CCM minimum roster sizes are as follows:

• Eligibility is based on a physician’s roster size on March 31st of the current bonus year
• In each bonus year, a physician must have a minimum roster size of 650 enrolled patients on March 31st of the bonus year being claimed.
• New Graduates in their first year of practice with a FHG or CCM will be required to have a minimum roster size of 450 enrolled patients on March 31^st of the bonus year being claimed.

Note: Minimum roster size is calculated based on the physician’s enrolled patient roster on March 31st of each year. Physicians must ensure they promptly submit the Per Patient Rostering fee code to enroll their patients.

Each April and September FHG and CCM physicians are provided their Projected TPSR regardless of their roster size at that time.

Target populations and services categories

Influenza vaccine

Target population: consists of enrolled patients who are 65 years or older as of December 31^st of the fiscal year for which the bonus is being claimed.

Service Period: is the current flu season up to January 31st of the year for which the bonus in being claimed.

Service Codes reported: G590A, Q690A, Q691A, and tracking code Q130A

Pap smear

Target population: consists of enrolled female patients who are between 21 and 69 years of age, inclusive, as of March 31^st of the fiscal year for which the bonus is being claimed.

Note: Only patients who are sexually active should be used in the calculation for the bonus.

Service Period: is 42 months prior to March 31st of the fiscal year for which the bonus is being claimed.

Service Codes reported: G365A, L713A, L733A, E430A, E431A, Q678A, tracking code Q011A and exclusion code Q140A

Mammography

Target population: consists of enrolled female patients who are between 50 and 74 years of age, inclusive, as of March 31^st of the fiscal year for which the bonus is being claimed.

Service Period: is 30 months prior to March 31^st of the fiscal year for which the bonus is being claimed.

Service Codes reported: X178A, X178B, X178C, X185A, X185B, X185C, tracking code Q131A and exclusion code Q141A

Childhood Immunizations

Target population: consists of enrolled patients who are aged 30 to 42 months of age, inclusive as of March 31^st of the fiscal year for which the bonus is being claimed.

Service Period: by their 30^th month of age.

Service Codes reported: G538A, G688A, G689A, G840A, G841A, G844A, G845A, G846A, and G848A and tracking code Q132A

Colorectal Cancer Screening

Target population: consists of enrolled patients who are between 50 and 74 years of age, inclusive; on March 31^st of the fiscal year for which the bonus is being claimed.

Service Period: is 30 months prior to March 31^st of the fiscal year for which the bonus is being claimed.

Service Codes reported: L179A, Q700A, tracking codes Q133A and exclusion codes Q142A

Tracking and exclusion codes

• To better assist physicians in monitoring patient status and determining service levels achieved, tracking and exclusion codes have been introduced. When submitted, these codes will identify the patient as having received the preventive care service or identify the patient as having met the criteria for being excluded from the target population for a specific preventive care service. For example, if your patient informs you that they received their influenza vaccination at a flu clinic at work, then the tracking code can be submitted.
• Tracking and Exclusion codes may be submitted using the normal billing practices used to submit Fee for Service claims and premium codes applicable to their agreement. As with other tracking codes, the fee billed should be zero dollars, and the fee paid on the Remittance Advice (RA) will be zero dollars with explanatory code 30 - “This service is not a benefit of OHIP”. Exclusion codes may be submitted if the patient meets the exclusion criteria listed below.

If you have changed your Electronic Medical Record (EMR) and are now with a different vendor, please ensure that the new EMR will accept claim submissions without a health number, date of birth and version code in preparation for submitting for the next preventive care bonus.

The Information and Procedures for Claiming the Cumulative Preventive Care Bonus document can be found on the Ministry of Health website.

Keywords/tags

Preventive Care Bonus Projected Reports; Target Populations and Services categories; Physician Eligibility; Tracking and Exclusion Codes

Contact information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524.

Find INFOBulletins online on the Ministry of Health website.